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Dyspareunia ˌdis-pə-ˈrü-nē-ə, -nyə

by Rosemary Basson, MD

Dyspareunia is pain when sexual intercourse or other sexual activity that involves penetration is attempted or pain during these activities.

  • The pain may be superficial or deep.

  • It may result from vaginal dryness or disorders of the genital organs.

  • The diagnosis is based on symptoms and a pelvic examination.

  • Anesthetic ointments, lubricants, exercises to relax pelvic muscles, or a change in the position for intercourse may help.

  • The cause, if identified, is treated.

The pain may be superficial, felt in the area around the opening of the vagina (genital area or vulva). Or the pain may be deep, felt within the pelvis when the penis or a dildo is thrust further inside. The pain may be burning, sharp, or cramping. Pelvic muscles tend to become tight, which increases the pain, whether it is superficial or deep.

Pain, including dyspareunia, is greatly affected by emotions. For example, minor discomfort may feel like severe pain after a traumatic sexual experience, such as rape. Anger toward a sex partner, fear of intimacy or pregnancy, a negative self-image, or a belief that the pain will never go away may make the pain feel worse.

Causes

Causes vary depending on whether the pain is superficial or deep.

Superficial pain

Intercourse can be painful because the vagina does not secrete enough fluids. Then the vagina feels dry, and lubrication for intercourse is inadequate. Inadequate lubrication often results from insufficient foreplay. Also, as women age, the lining of the vagina thins and can become dry because estrogen levels decrease. This condition is called atrophic vaginitis. During breastfeeding, the vagina may become dry because estrogen levels are low. Taking antihistamines can cause slight, temporary dryness of the vagina.

Superficial pain may also result from the following:

  • Increased sensitivity of the genital area to pain (provoked vestibulodynia—see Provoked Vestibulodynia (Vulvar Vestibulitis)), which is the most common cause

  • Inflammation or infection in the genital area (including genital herpes), the vagina, or Bartholin glands (the small glands on either side of the vaginal opening)

  • Inflammation or infection of the urinary tract

  • Injuries in the genital area

  • Radiation therapy affecting the vagina, which can make the vagina less elastic and can cause scarring, making the area around the vagina smaller and shorter

  • An allergic reaction to contraceptive foams or jellies or to latex condoms

  • Involuntary contraction of the vaginal muscles (vaginismus)

  • Rarely, a congenital abnormality (such as an abnormal partition within the vagina) or a hymen that interferes with entry of the penis

  • Surgery that narrows the vagina (for example, to repair tissues torn during childbirth or to correct a pelvic floor disorder—see Pelvic Floor Disorders)

The hymen is a membrane that encircles or, in a very few women, covers the opening of the vagina. When women have sexual intercourse the first time, the hymen, if not previously stretched (for example, from tampon use or sexual stimulation with a finger inside the vagina), may tear, causing some pain and bleeding. A few women are born with an abnormally tight hymen.


Deep pain

Deep pain during or after sexual intercourse may result from the following:

  • Infection of the cervix, uterus, or fallopian tubes (pelvic inflammatory disease), which may cause collections of pus (abscesses) to form in the pelvis

  • Endometriosis

  • Growths in the pelvis (such as tumors and ovarian cysts)

  • Bands of scar tissue (adhesions) between organs in the pelvis, which may form after an infection, surgery, or radiation therapy for cancer in a pelvic organ (such as the bladder, uterus, cervix, fallopian tubes, or ovaries)

Sometimes one of these disorders (such as fibroids) causes the uterus to get stuck in a bent-backward direction (called retroversion), resulting in deep pain. Strong unintended (involuntary) contraction of the muscles in the pelvis (called pelvic muscle hypertonicity) can cause or result from deep pain.


Diagnosis

The diagnosis is based on the woman’s description of the problem, including when and where the pain is felt, and on the results of a physical examination. The genital area is gently but thoroughly examined for possible causes, such as signs of inflammation or abnormalities. If doctors find an abnormal area, they may take a sample to be examined under a microscope (biopsy).

A doctor may touch the area gently with a cotton swab to determine where the pain occurs. The doctor checks the tightness of the pelvic muscles around the vagina by inserting one or two gloved fingers into the vagina. To check the uterus and ovaries, the doctor then places the other hand on the lower abdomen. A rectal examination may also be done.

Treatment

Couples are encouraged to find ways to attain mutual pleasure (including having orgasms and ejaculation) that do not involve penetration—for example, stimulation involving the mouth, hands, or a vibrator.

For superficial pain, applying an anesthetic ointment and taking sitz baths may help, as may liberally applying a lubricant before intercourse. Water-based lubricants rather than petroleum jelly or other oil-based lubricants are preferable. Oil-based lubricants tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. Spending more time in foreplay may increase vaginal lubrication.

For deep pain, using a different position for intercourse may help. For example, being on top can give women more control of penetration, or another position may limit how deeply the penis can be thrust.

More specific treatment depends on the cause, as in the following:

  • Thinning and drying of the vagina after menopause: Estrogen inserted into the vagina as a cream (with a plastic applicator), as a tablet, or in a ring (similar to a diaphragm) or taken by mouth (as part of hormone therapy)

  • Infections: Antibiotics, antifungal drugs, or other drugs as appropriate (see )

  • Cysts or abscesses: Surgical removal

  • A rigid hymen or another congenital abnormality: Surgery to correct it

Psychologic therapies, such as cognitive-behavioral therapy and mindfulness-based cognitive therapy (MBCT—see Treatment), may benefit some women. Mindfulness involves focusing on what is happening in the moment, without making judgments about or monitoring what is happening.

Pelvic muscle relaxation exercises, sometimes with biofeedback (see Mind-Body Techniques : Biofeedback), can help women with tight pelvic muscles learn to consciously relax them.